Gap Cover is a short-term insurance product designed to provide extra protection against significant medical expense shortfalls. It covers the ‘gap’ between what your medical scheme pays out and the actual rates charged by private healthcare professionals.
For unexpected illness or in situations when urgent medical care is needed (like an accident), your medical aid might not cover the costs and you may not have enough time to make financial plans to accommodate the care you need.
Most brokers and even some medical aid providers recommend that clients take out gap cover. Imagine a scenario where you are hospitalised and upon discharge, you get a large hospital bill and realise that your medical aid scheme may not cover all the costs. In some cases, specialists in South Africa, refuse to perform certain surgeries on people who do not have gap cover. The reason for this being that they regularly experience partial payments from medical aid schemes and consider gap cover as a form of insurance in knowing that the full payment will be made.
Whether you’re young and healthy or ageing and have concerns about your health, gap cover is an essential protection to consider. Although many believe that having a medical aid or hospital plan is sufficient cover, there are many cases where the payout from your medical scheme simply doesn’t match the actual fees charged for particular medical procedures. In these cases, you’re left to pay the difference on your own.
To fully understand why gap cover is an essential addition to your medical scheme benefits, think about some examples of common procedures and their costs, the amounts covered by a medical aid scheme and – if you do not have gap cover – the amount you will be left to pay out of your pocket.
It may come as a shock to many people after they realise that even if you have medical aid, you could be confronted with crippling medical costs if you or a close family member requires treatment for illness or after an accident.
If you are 60 years of age or younger and are part of a registered South African medical aid scheme, you qualify for gap cover. This can include your spouse and dependent children up to a certain age, as long as all members of your family belong to your medical scheme and the same medical aid plan or option.
The same as conventional medical aid, waiting periods and exclusions apply to gap cover.
Generally, there is a waiting period of three months for all benefits, as well as a 12-month waiting period for pre-existing conditions. Throughout these waiting periods, you and your family are not eligible for cover.
There are certain procedures and treatments (exclusions) that are not covered by gap cover benefits. These may differ according to the provider. Typical exclusions include cosmetic surgery, specialised dentistry and obesity treatment. Gap Cover products will only address medical expense shortfalls for something that has been moderately covered by your Medical Scheme. For example, if your Medical Aid doesn’t cover a particular procedure or specialist bill at all, then, unfortunately, your Gap Cover will not able to assist.
If you currently have a medical aid plan and want to cover yourself fully against the difference in your cover and medical fees, you can compare Gap Cover quotes side-by-side from some of the top insurers in South Africa. Our Gurus are also on standby to help with any of your questions or to help you choose and open a policy.